Fall 2014 - Update
Agency For Healthcare Administration [FLORIDA]
Medicaid Managed Care Update:
The Agency will continue to engage in outreach activities
for recipients, providers and health plans in these regions through the 90-day
post-enrollment continuity of care period. Information about the program can be
found by visiting the Statewide Medicaid Managed Care website. Those who are
interested can view a series of recorded provider webinars by visiting the
Agency’s YouTube channel or access the slide decks by visiting the Agency’s
Slide share profile. As the SMMC program moves toward “steady state,” the
Agency will continue to focus on supporting program stakeholders and enforcing
the provisions set forth in Florida Statute.
Medicaid Compliance:
In conducting a review of your practice, providers will
want to look at both the claims submitted to Medicaid for reimbursement as well
as the processes and protocols used within your practice. Making sure that you
minimize billing for medically unnecessary or duplicate services is another way
to reduce the chance of being audited by government officials. Providers should
also look at patient outcomes and ensure that their practices are resulting in
better quality of care for their patients. The Agency routinely discovers
instances where providers have billed for services not rendered, billed for
unnecessary services, failed to maintain required documentation, or the
documentation maintained is outdated or incomplete. There have been billing and
coding errors, and personnel file non-compliances such as background screening
or training requirements. Providers who institute compliance plans and conduct
routine reviews of their claims to Medicaid in conjunction with their records
(both medical records and business records) are at a much lower risk for being
audited and if audited, to have adverse findings.
Medicaid Onsite Visit to Increase:
During FY 2014-15 Medicaid providers should anticipate
additional onsite and desk reviews to be conducted by both the Agency and
managed care plans connected with the Agency. The Agency’s Office of Inspector
General, Medicaid Program Integrity, intends to conduct compliance site visits
to providers of different specialties throughout the state of Florida. The
Agency will continue to monitor for providers who have changed addresses and
either failed to update their provider enrollment information altogether, or
have updated only their primary provider identification number and failed to
ensure that all provider identification numbers are updated as applicable.
Compliance reviews also include compliance regarding professional licenses, any
local government licensure such as: business tax receipts, accuracy of service
address on Medicaid’s enrollment files, and compliance in regard to
confidentiality and record storage.
Ø
Is your practice in Compliance ?
Ø
Are the levels of service submitted correct ?
Ø
Have you completed the Security Policy Manual ?
Ø
Have you audited your Electronic Health Record
System?
Ø
Are you capturing the Meaningful Use data ?
Ø
Are your Coding for HEDIS?
Ø
Does your Documentation meet the required data
for HEDIS ?
Failing to comply with these regulations can and will
cause your office to have an Audit.
As AHCA is indicating be prepared for Onsite visits , and be prepared to
show:
- billing for medically unnecessary or duplicate services
- billing and coding errors
- personnel file non-compliances such as background screening or training requirements
- Providers should also look at patient outcomes and ensure that their practices are resulting in better quality of care for their patients
Providers need to understand:
Ø Coding
Ø CCI
Ø LCD’s
Ø HEDIS
Ø PQRS
Ø ICD-10
Since
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